Iron-Deficiency Anemia: Management

Iron-Deficiency Anemia: overview

This algorithm addresses iron-deficiency anemia, identified by a low ferritin, and moves through evaluation of the source, first-line repletion and indications for intravenous iron.

The first step is to identify the cause, including gastrointestinal evaluation and assessment of menstrual losses, with endoscopy if the deficiency is unexplained. First-line repletion uses oral iron given on alternate days, which offers better absorption and tolerance. Intravenous iron is the second-line option, indicated for intolerance of oral iron, malabsorption, chronic kidney disease or ongoing blood loss. The chart emphasizes that repletion and investigation of the underlying cause proceed together, and that oral iron remains the starting point for most patients unless one of these specific indications favors intravenous iron.

Trials behind this algorithm

PIVOTAL Macdougall IC et al, NEJM, 2019; PMID: 30365356

Background reading: Iron deficiency anemia board review notes.

Iron-Deficiency Anemia: the algorithm in words

Starting point: Iron-deficiency anemia (low ferritin). Full background: Iron deficiency anemia notes.

Evaluate source (first-line): Work-up: Identify cause (GI eval, menstrual) (endoscopy if unexplained).
Replete: first-line (first-line): Oral: Oral iron (alternate-day) (better absorption / tolerance).
IV iron (second-line): Indications: IV iron (intolerance, malabsorption, CKD, ongoing loss).